As you can see by just looking around that the look of the web site is different.  This comes from a new format, thanks to iThemes and updated software from WordPress.  With all of the revamping going on, the work has spird me into more diligence in keeping things rolling here.  The result is that there should me more frequent updates and added content to the web site in the coming months.  Stay tuned and again thank you to all the well wishers.

Now, lets eat!

This year I have been really privileged to participate in the recent graduation of our 2008 class here at USC.  The slide show that was put on by JR included many of the pictures that I took over the past two years of this SRNA group.  They were great to work with and I am sorry that they are now all gone on to study for Board Exam.  One of the things that I have been working on for the past couple of years now is a CRNA board review class that is given to the seniors during their final year before graduation.  Dr. Michele Gold and I will be starting this review again next month and the series will run until graduation next August.  The preparation for these reviews in tremendous but wonderful.  It keeps me in tune.

What prompted me to write after a little layoff was a recent comment by Wes.  Here it is for your enjoyment:

Hello Everyone,

I’ve recently finished reading through most, if not all, of the blogs here on the site. I am really impressed and have enjoyed this personal perspective into the field that I haven’t found on other NA websites including the AANA. Reading through this blog has been a real treat and I consider it half pleasure reading and half personal research into a field that I have increasing interest in.

When I was a nursing student, I must admit that I found the profession to be boring and full of magazine reading. Now as a nurse working in a neuro-surgical-surgical-trauma ICU, I admit that I had no idea of the awesome responsibility and greatly expanded knowledge base of the CRNA. Gaining experience with mechanically ventilated patients receiving anesthetic and analgesic drips, I am beginning to realize just how little I know and how much more I want to know about anesthesia.

This once seemingly “boring” profession is starting to become so very interesting to me as I read websites such as this and as I care for post-surgical ventilated and sedated patients. I also enjoy picking the brains of the anesthesia residents as they do rotations on our unit and find them to be quite knowledgeable.

I apologize for the long personal story, but I just wanted to say thank you for the great insight of all those who have contributed to this site from every step of the journey.

David, I must congratulate you on your hard earned achievements! Reading through the older blogs gives us an idea of how strenuous this journey really is. The great tips on applying to CRNA school and surviving once your in…have been helpful to many I’m sure.

Finally, living so close to USC in neighboring San Bernardino county I can’t help but inquire if you or your colleagues would be interested in taking on yet another “shadow.” Please e-mail me when you find some free time. Thanks again.

Wes

Thank you Wes for really nailing it for me.  Your perception of what this blog is all about is exactly right.  When I started out looking into becoming a CRNA there was nothing on the web where I could find real information about what it was like to be a CRNA, how to get in to a program or what it took to really shine as a student nurse anesthetist.  So I did it myself!

Now the torch is past along to those eager students willing to tell their stories and share their experiences with others.  I invite any interested in becoming a CRNA or those students already in programs to write to me and I will put it “up on the web” for others to read, learn from and be inspired by to become the best they can be.  For me this has been as a nurse anesthetist.  I have never regretted one moment of that decision to go for it.

DG

Dear David,

As I was eagerly reading your blog I could feel my pulse furiously pounding in my neck…. right before I read the part that said
“If you just take a self-check now and measure your pulse you will know.” ….and then I knew I wasn’t crazy, I just have a burning desire for the field.

I will begin my BSN studies at Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, MO this coming January. Upon completing my BSN I will then start the path of working my way toward my acceptance into the CRNA program at this same institution.

I am currently an IT professional with AT&T (4 years). I graduated with a BS in Information Systems from Maryville University outside St. Louis, MO in May of 2004. College was a long road for me as I was ill due to what was later discovered as congenital heart defect (ASD), which was successfully repaired mid-college career. This of course was a delay, thus I hastily settled for an IT major knowing my dream was to be a CRNA.

Well… all that aside, the fire has kept burning and I am going to keep it stoked by pursuing my dream. I am VERY excited to begin my nursing studies. I realize I have quite a rigorous road ahead of me, but reading blogs like yours creates even more desire for the challenge.

I am thankful to have read your blog. Congratulations on your hard earned success. One day I will be in your shoes encouraging future CRNA’s.

C. J.

Hello David( aka Professor Plum)

Congratulations on living up to your true destiny, not only a CRNA but a professor also! Remember me, from the CTICU way back when you were down in the trenches?  I came across your blog as recommended by one of your current students.

I am so proud of you! The reason for my email is a plea for help. I resigned from UCLA 12/2007 so that I could be with my love who moved to Oklahoma City. I now live in OKC , the transition was very tough but worth it. During that time I reflected heavily about what it is I actually want to do with my life. I have decided to once again pursue my dream of becoming a CRNA. I guess my ego was shattered by the one and only denied application years ago, I think you were still on the unit , 2003 I believe then.

Anyway, for years I watched many of my fellow coworkers pursue what I wanted enviously but didn’t have the “fire” or confidence in myself since my rejection. Over the years I have been on the front lines in CTICU, even moved up to the ranks of the especially strong- THE CHARGE NURSES- can you believe it? Anyway, enough babbling, I have the fire, the intense desire to pursue this dream. I plan to apply to several programs in Florida, 1 in Maryland, and 2 in Texas. Haven’t taken the GRE yet, but have a good GPA when I graduated form U of Maryl.

What do you think? Any words of wisdom? My experience is strong, I think I interview well, just scared about the GRE I guess. I remember someone, I think it was you, saying to not bother taking the review courses through Kaplan or Princeton Review. Also, what most do you like to see in a personal statement? David, I know it’s been a long time, but as you hopefully recall, I always respected your input. You were one of my senior advisers then and I hope you can give me some pointers now. I hope all is well with you and am looking forward to hearing from you.

Respectfully, M. B.

Q: I am a CRNA in the CA BRN Diversion Program. My contract requires me to attend a variety of 12 step program meetings. I don’t feel like they are helping me because I don’t believe in God. In fact, this is exactly why I do not want to attend anymore.

A: You raise an interesting point, and you are certainly not alone. There are some key points to consider here. First, Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) do not mandate anybody to believe in God. Twelve step programs also have 12 Traditions, necessary for the cohesiveness and effectiveness of the group.

The Third Tradition states, “The only requirement for membership is a desire to stop drinking/ using”, therefore the atheist or agnostic cannot be denied. Next, the Second Step states, “Came to believe that a power greater than ourselves could restore us to sanity”. We believe in a Higher Power and yes, the vast majority of members choose to believe that God is their Higher Power. Many have even taken the word “God” and made their own acronym, such as “Good Orderly Direction” It is also common to see members using the AA or NA group as their Higher Power; or nature. In the Third and Eleventh Steps where God  is mentioned, it is immediately followed by, “as we understood Him”, because this is highly subject to personal belief and interpretation. Lastly, the only suggestion I would like to offer is to try to have an open mind. If you focus on what makes you different from everyone else in the group, then you will feel isolated and alone. If you focus on the similarities and concentrate on identifying instead of comparing- then you will start to feel “part of” rather than “apart from”.

Q: I am a newly recovering opiate addict/ CRNA. The counselor at my treatment center tells me that I cannot drink alcohol. I don’t even like alcohol! I would much rather do other things. I’ve never had a drinking problem, so I don’t understand why I cannot have a glass of wine with my dinner every now and then.
A: I can sum up the answer in one sentence: “If you can”t have the drug you love, you love the drug you’re with”.  What does that mean?
The basic pathophysiology in the brain can be explained very easily. Anything that is addicting, whether it is opiates, ethyl alcohol, benzodiazepines, cocaine, et cetera- all follow the same final common pathway. At the base of the brain is a structure called the ventral tegmental area (VTA) which projects dopamine to the nucleus accumbens in the frontal cortex. Therefore, whether you are tickling mu receptors, enhancing GABA, or blocking the reuptake of norepinepherine- it will invariably result in a rush of dopamine in the frontal cortex. This rush of dopamine is what we seek; it is the high that addicts crave.
Interestingly enough, whenever there is activity associated with procreation or survival (such as sex and food), the pathway of dopaminergic projection is identical. This is a deeply embedded, primitive pathway. It explains why addicts and alcoholics will do whatever it takes to get their fix- because it is as important as procreation and survival. It becomes a primal drive.
Back to the original question of why an opiate addict cannot drink alcohol: the brain does not know the difference. Even if alcohol is not your drug of choice, you are still pushing the dopamine button. There are countless anecdotal instances of people who, for example, are primary alcoholics who relapse on hydrocodone. Or primary opiate addicts who become full-blown alcoholics. (As a side note, taking pain medication on a short term basis for injury or surgery is an entirely different Q&A.)
If anyone is interested, I would be happy to share some scientific articles via e-mail. Abstaining from all mood and mind-altering substances is an evidence-based suggestion for all addicts and alcoholics. The disease is cunning, baffling and powerful. It is also very patient. It will wait a lifetime for you to pick up again.
Heather Wilson, CRNA, MS
AANA Peer Assistance Advisors Committee
Co-chair CANA Peer Assistance
mocrumbo(at)sbcglobal.net

The first place to start is to narrow down your reading material. The large text books like Barash and Miller are great for general study and case preparation during your clinical years. When it comes down to the wire and time is getting pinched look for other reading material to help you prepare for boards. I suggest a couple of books. The Basics of Anesthesia, 5th ed edited by Stoelting and Miller is a great start as well as Morgan and Mikhail. Anesthesia Review by Faust is really top notch as well as the question and answer books like Anesthesia Secrets. Two books that I feel really are essential are Anesthesia and Co-existing Diseases by Stoelting and Review of Medical Physiology by Ganong. What I suggest is to read these two texts again during the last 6 months of clinical rotations. There is an amazing amount of physiology on the board test as well as stuff found in the Co-existing book.

Other review material and courses are listed below that I have found.

Valley Anesthesia review is a long time standby for board prep offering both review courses and valuable study material. Highly recommended.

Core Concepts Anesthesia Review On line course. I just ran into these folks the other day and they seem legitimate. I poked around their web site and found some interesting stuff like the Question of the Day. Recommend checking their service out.

Prodigy Anesthesia Review is an interesting web site presence. Like the Core Concepts place, here you can find pracitce exams that look very close to the real thing. Check them out and let me know what you think.

CRNA Secrets is another one that I need info on. Please check it out and let me know what you think of this guy!

Good luck and keep me informed about your progress.

Enjoy!

Most graduate education is difficult. I should know, this last effort was a second post graduate degree. However, in nurse anesthesia education the stakes are higher and many people feel its their duty and privilege to make life difficult for the prospective candidate for the Certifying Nurse Anesthesia exam. The gauntlet that the student runs is like a small alley way lined on both sides with angry frustrated preceptors that are wielding long bamboo sticks. Any unworthy student trying to run down the alley is beaten from both sides as they try to make it through. You think I am kidding – well maybe the allusion is too graphic but the idea still holds. In the words of one old timer mentor, “Yup, we love to cull the herd!” So its taken me a little time to recuperate from the last two years of very hard work getting through clinical residency. All of the bruises are healed but the scares still remain.

Now I am one! One what you ask. Well now I am one of the mentors and the bamboo is put away.  You’re laughing I am hoping, yes? Actually I have been very fortunate and have been appointed to a faculty position at a leading Medical School that houses a nurse anesthesia program. Just little over six months ago I was a student and now I hold a faculty position with my own students to ed-u-ma-cate. I am humbled by the position I am in and having the time of my life. Love it! The perspective from the other side is of course different but I try to hold on to the kindness for others that suffering produces.

One of the questions that was asked of me during my interview process for the faculty position at the University of Southern California was how I would deal with a difficult student one who is not progressing or one that is not safe clinically. To be honest I do not feel that I am ready to deal with this case scenario and told them so. I can handle the new student and the ones that are a quick study. Maybe next year I will have a bit more experience to handle the difficult student. Just as an aside I do have many years of as a preceptor in another capacity so teaching and mentoring is not new for me.

So whats it like to be in practice now as a nurse anesthetist. Wonderful – I love my job and what I do. In our practice setting we work in a team collaborative practice with anesthesiology. The joint practice is great when the Staff are good. Every day is another learning experience which I can talk about in the future. For now I just wanted to touch bases with you and let you know that the NurseAnesthetist.org web site is still going strong. I will be recruiting new writers in the months to come and adding links that should prove helpful to the prospective CRNA or clinical resource for the practicing nurse anesthetist.

Your feedback is always encouraged so let me know what your ideas or concerns are. Thanks for reading.

Currently Jennifer and I are in Shanghai visiting her parents for the Chinese Moon Festival. Each morning I would get up first thing and turn the computer on and go to the AANA web site looking for the board exam results. I know that sounds nuts but I just could not wait for the mail and the end of our trip overseas to find out the results of the board exam.

So what can I now recommend as study preparation for the board exams you ask. First I would not put off any review for the board exam but to study daily the entire time while doing clinical rotations. A through review of medical physiology is a must. My choice is the LANGE publication by Ganong, “Review of Medical Physiology” as a must read. This is not a large text but dense and will require several months of careful reading and rereading to gather the appropriate understanding of the specific anatomy and physiology that is required knowledge to do well on the nurse anesthesia board exam. Maybe I could give you a general example of how specific the board exam is.

One of the favorite subjects on the board exam has been the endocrine system and the interactions with anesthesia. The pituitary glad as you may recall is located in the Sella Tursica, a cave like bony structure and is histologically divided into three sections. In humans the intermediate lobe section is underdeveloped and rudimentary. The posterior pitutiary or neurohypophysis is the site of excretion of ADH (vasopressin) and oxytocin which are structurally similar. It is interesting to note that oxytocin has antidiuretic qualities because of the structural similarity of these two hormones. I digress. The point I am getting to is that the source of the posterior pituitary hormones in from higher structures in the hypothalamus, specifically the supraoptic and paraventricular nuclei. Nerve axons project from these structures and descend out of the “Blood brain barrier” down to the posterior pituitary where they are released when physiologically stimulated. A full review of this and all of the physiology surrounding these structures and the actions of all of the hormones along with the anesthesia implications is highly suggested. Ganong’s Review of Medical Physiology and the Anesthesia and Co-existing Disease book by Stoelting are both highly recommended.

Brother, that was a mouth full. So which part of this do you need to know to pass boards? I am afraid that this is just a small example of the detail between structure and function that is requried. Its been overwhelming and the more that I study the more I realize that I know very little.

Good luck to all that are preparing for the board exam and don’t forget the small details. I guess it would be correct to say that knowledge at a superficial level will leave you really perplexed when you take boards while knowing the fine details will help you navigate your way through the questions. Again good luck.

Just as all others that have come before and for those that follow there no way around this mountain except to climb each day a little further. I have kept a picture of K2 on my wall for many years and I keep whispering to myself that one day I will be over the crest. That day is so soon approaching that it is almost too much to comprehend.
Here is a plan for CCRN board exam preparation that I have used:

Attend a Review Course. I did the Valley Anesthesia Review, there are others?
Select a few concise books for reference.

• Morgan and Mikhail Clinical Anesthesiology
• Barash Handbook
• Sota Omoigui’s Drug Handbook.
• Valley Review Course material. The Sweat Book, the Memory Master and the Mixed Reviews.
• Anesthesiology Review by Ronald Faust

I have read through the Sweat Book twice and the Memory Master a couple of times and The Mixed Reviews from Valley anesthesia I keep with me all the time. I read through these frequently.

The Faust Anesthesiology Review is a great one to look stuff up quickly for refresher. These past three weeks since graduation I have spent 6 to 10 hours a day reading and reviewing questions and looking stuff up quickly that I needed clarification on. I feel that I am ready for the exams but still have so much to learn. I just found out about another on-line review that could be helpful. It is called Prodigy Anesthesia. This is an on-line review and workbook type thing. I checked it out and it seems very good. Highly recommended for someone that has more than a couple of days before the scheduled exam. Another board prep on line I found is CRNA Secrets. If you do check it out let us know if it helped or not with boards.
Thanks to everyone for the well wishes. Our class will get together for a big party once these exams are over so every one will know about our success.

Our lives have been enriched by his mentorship and example of excellence in patient centered anesthesia care. Thank you Dr. Bob Naruse and we will all make you proud. What follows is a letter I received from him after today’s presentation.

Dear ‘SC Class of 2006,I must admit that I am truly touched by your award. Working with such a distinguished group of anesthetists made my job easy and fun. I can’t remember a class that I’ve enjoyed more than yours. I know that each of you will be outstanding anesthetists for years to come and I want to congratulate each of you for the great achievement of completing graduate school. I am proud of you.

Please pass along your knowlege, especially that which is not in the textbooks. I know that eventually your colleagues will be impressed with your airway management skills as am I. We owe it to our patients to provide the best care possible.

Take care and best wishes in the future. Fight On!!!

Yours truly,
Bob Naruse
Da cedarsgasman

So there you have it. This week many of us are studying for CCNA board exams. My test date is the 20th of this month. Pressure, a little, confidence, a lot. I will let you all know how our class does.